Download Absence of Inferior Gluteal Artery: A Rare Observation

Int. J. Morphol.,
25(1):95-98, 2007.
Case Report
Absence of Inferior Gluteal Artery: A Rare Observation
Ausencia de la Arteria Glútea Inferior: Una Rara Observación
Sreenivasulu Reddy; Venkata Ramana Vollala & Mohandas Rao
REDDY, S.; RAMANA, V. V. & RAO, M. Absence of inferior gluteal artery: A rare observation. Int. J. Morphol., 25(1):95-98, 2007.
SUMMARY: The gluteal region is an important anatomical and clinical area which contains muscles and vital neurovascular
bundles. They are important for their clinical and morphological reasons. In this manuscript we report a rare case of absence of inferior
gluteal artery. In the same specimen the superior gluteal artery was taking origin from the anterior division of internal iliac artery. The
structures normally supplied by the inferior gluteal artery were supplied by a branch coming from the superior gluteal artery. The
developmental and clinical significance of the anatomical variation is discussed.
KEY WORDS: Internal iliac artery; Inferior gluteal artery; Superior gluteal artery; Anatomical variation.
INTRODUCTION
Normally, the internal iliac artery begins at the
common iliac bifurcation, at the level of sacroiliac joint. It
descends posteriorly to the superior margin of the greater
sciatic foramen where it divides into an anterior trunk and a
posterior trunk. The branches arising from the posterior trunk
include iliolumbar artery, lateral sacral arteries and superior
gluteal artery. The anterior trunk gives superior vesical artery,
inferior vesical artery, middle rectal artery, vaginal artery,
obturator artery, uterine artery, internal pudendal artery and
inferior gluteal artery.
The inferior gluteal artery is the larger terminal branch
of the anterior division of internal iliac artery and principally
supplies the buttock and thigh. It descends posteriorly, anterior to the sacral plexus and piriformis muscle but posterior
to the internal pudendal artery. It passes between the first
and second or second and third sacral anterior spinal nerve
rami, then between the piriformis muscle and
ischiococcygeus muscle. It runs through the lower part of
the greater sciatic foramen to reach the gluteal region (Fig.
1). The artery runs inferiorly between the greater trochanter
and ischial tuberosity with the sciatic and posterior femoral
cutaneous nerves deep to gluteus maximus muscle. It
continues down the thigh, supplying the skin and
anastomosing with branches of the perforating arteries.
The inferior gluteal and internal pudendal arteries often
arise as a common stem from the internal iliac,
sometimes with the superior gluteal artery. Inside the
pelvis the inferior gluteal artery gives branches to
piriformis, ischiococcygeus and iliococcygeus
muscles. Occasionally, it contributes to the middle rectal arterial supply and, in male, supplies vessels to the
seminal vesicles and prostate (Standring, 2005).
The superior gluteal artery is the largest branch
of the internal iliac artery and effectively forms the
main continuation of its posterior division. It runs
posteriorly between the lumbosacral trunk and the first
sacral ramus or between the first and second rami, then
Fig. 1. Normal arterial pattern of gluteal region
Department of Anatomy, Melaka Manipal Medical College (Manipal Campus), ICHS, Manipal, Karnataka-576 104, India.
95
REDDY, S.; RAMANA, V. V. & RAO, M.
turns slightly inferiorly leaving the pelvis by the greater
sciatic foramen above piriformis muscle and dividing into
superficial and deep branches (Fig. 1). In the pelvis it
supplies piriformis and obturator internus muscles and a
nutrient artery to the ilium. The superficial branch enters
the deep surface of gluteus maximus muscle. Its numerous
branches supply the muscle and anastomose with the inferior gluteal artery branches while others perforate the
tendinous medial attachment of the muscle to supply the
skin over the sacrum where they anastomose with the posterior branches of the lateral sacral arteries. The deep branch
of the superior gluteal atery passes between gluteus medius
muscle and bone, soon dividing into superior and inferior
branches. The superior branch skirts the superior border of
gluteus minimus muscle to the anterior superior iliac spine
and anastomoses with the deep circumflex iliac artery and
the ascending branch of the lateral circumflex femoral
artery. The inferior branch runs through gluteus minimus
muscle obliquely, supplies it and gluteus medius muscle
and anastomoses with the lateral circumflex artery. A branch
enters the trochanteric fossa to join the inferior gluteal artery
and ascending branch of the medial circumflex femoral
artery while other branches run through gluteus minimus
muscle to supply the hip joint (Standring).
CASE REPORT
During routine dissection of the
right gluteal region of an adult male
cadaver, we observed a rare variation of
absence of inferior gluteal artery
compensated by a branch coming from superior gluteal artery. The origin of superior gluteal artery was different from normal; it came from anterior division of
internal iliac artery (Fig. 2).
The superior gluteal artery took
origin from the anterior division of internal
iliac artery, passed through the greater
sciatic foramen and appeared in the gluteal
region above the piriformis muscle. The
artery divided into superficial and deep
branches. The superficial branch passed
between the gluteus medius and maximus
muscles and supplied both of them, it also
gave an anomalous branch which replaced
the inferior gluteal artery and accompanied
the inferior gluteal nerve. The anomalous
branch supplied the adjacent muscles and
took part in cruciate and trochanteric
anastomoses. There was no inferior gluteal
artery in the specimen.
DISCUSSION
Anatomical variations of gluteal
region are well documented but the
absence of inferior gluteal artery has never
Fig. 2. Absence of inferior gluteal artery compensated by an anomalous branch arising
from superior gluteal artery. SGA. Superior gluteal artery; AB. Anomalous branch;
IGN. Inferior gluteal nerve; P. Piriformis muscle; GM. Gluteus maximus muscle.
96
Absence of inferior gluteal artery: A rare observation. Int. J. Morphol., 25(1):95-98, 2007.
been reported in the literature. Primarily, the gluteal region
contains the diverging elements derived from the sacral
plexus and internal iliac vessels. According to Bergman et
al., (1988) the inferior gluteal artery may form a common
trunk with the superior gluteal artery, it may be doubled
and may join the obturator artery.
According to Bergman et al., the internal iliac artery
may give branches without dividing into anterior posterior divisions and branches of the anterior and posterior
divisions of the internal iliac artery may exchange origins.
The axial artery (sciatic artery) is the major arterial
supply to the lower limb bud at an early embryological
stage. It primarily originates from the dorsal root of the
umbilical artery. After the 22 mm embryological stage, the
sciatic artery involutes and the femoral artery system
develops as the major inflow source to the lower limb. In
the adult, remnants of the sciatic artery persist as the
proximal portion of the inferior gluteal artery, the popliteal
and fibular arteries (Standring). In the present case the
sciatic artery has persisted as the proximal portion of the
superior gluteal artery.
Construction of any graft or flap requires very
accurate knowledge about the vascular supply. The
ramification of superficial branch of superior gluteal artery
is used to construct skin flaps. In the buttock it is commonly
known that the superior gluteal artery separates into two
main branches, namely the superficial and deep branches.
According to Kida et al., (1992) the superficial branch of
the superior gluteal artery constantly divides into two main
branches, which are called the ascending and transverse
branches. Of the ascending and transverse branches, one
or both usually give off at least one well developed division
running on the undersurface of the gluteus maximus muscle
(98.2%). This division, which is called the intermediate
branch in their study, generally reaches the superior edge
of the muscle giving off only a couple of muscular branches
and pierces the muscle and its deep fascia to supply skin
(83.6%). The authors have investigated 56 sides of 33
Japanese cadavers to see the ramification of the superficial branch of the superior gluteal artery. In the current
manuscript the anomalous branch originated from the
intermediate branch and replaced the inferior gluteal artery.
Ischemic buttock claudication is generally due to
lesions of the common iliac or internal iliac vessels,
especially if the collateral circulation is compromised
(Hassen-Khodja et al., 1987). However, buttock
claudication can also be caused by isolated stenosis of the
superior gluteal artery in the absence of atheromatous
involvement of the other arteries (Batt et al., 1997, Cook
& Dyet 1990). The observation of superior gluteal artery
stenosis in the absence of atheromatous disease suggests
the existence of an anatomic cause, and in particular arterial
compression at the level of the suprapiriformis canal. In a
study by Bouillanne et al., (1999) anatomic, angiographic,
and CT findings all revealed the intimate relations between
the superior gluteal artery and the greater sciatic notch;
during its change in direction, the artery is pressed against
the bony surface by the fibromuscular structures and the
piriformis muscle, which form a true osseofibromuscular
trap. Moreover, sagittal CT reconstructions demonstrated
arterial calcifications at this level, whereas no such lesions
were observed immediately upstream or downstream.
Anatomopathologic study revealed the possibility of
elective stenosis at this point, and demonstrated that the
occluding lesion differs from classical atheroma. Along
its course in the suprapiriformis canal, the superior gluteal
artery is thus susceptible to stenosis involving specific
histologic modifications suggesting elective alteration of
the arterial wall due to repeated trauma. Depending on the
extent of collateral circulation that may differ from one
patient to another, this trap can lead to the development of
functional signs (Jutiano et al., 1994). "Entrapment" of the
superior gluteal artery should be suspected in patients who
present with isolated buttock claudication despite otherwise
normal vascular investigations. In the cases like the present
article, if the superior gluteal artery is compressed, the
blood supply to the gluteus maximus muscle will be
diminished since the inferior gluteal artery is absent.
REDDY, S.; RAMANA, V. V. & RAO, M. Ausencia de la arteria glútea inferior: Una rara observación. Int. J. Morphol., 25(1):95-98,
2007.
RESUMEN: La región glútea es una importante área anatómica y clínica, la cual contiene músculos y vitales elementos
neurovasculares. Estos últimos son importantes por razones clínicas y morfológicas. En este trabajo describimos un raro caso de ausencia de la arteria glútea inferior. Encontramos también que la arteria glútea superior tenía su origen en la división anterior de la arteria
iliaca interna. Las estructuras irrigadas normalmente por la arteria glútea inferior estaban irrigadas por una rama que se originaba de la
arteria glútea superior. Son discutidos el desarrollo y el significado clínico de esta variación anatómica.
PALABRAS CLAVE: Arteria iliaca interna; Arteria glútea inferior; Arteria glútea superior; Variación anatómica.
97
REDDY, S.; RAMANA, V. V. & RAO, M.
REFERENCES
Batt, M.; Desjardin, T.; Rogopoutos, A.; Hassen-Khodja &
Le Bas, P. Buttock claudication from isolated stenosis
of the gluteal artery. J. Vasc. Surg., 25:584-6, 1997.
Bergman, R. A.; Thomson, S. A.; Afifi, A. K. & Saadesh F.
A. Compendium of human anatomic variations. Urban
& Schwarzenberg, Baltimore, Munich, 1988. p. 84.
Correspondence to:
Venkata Ramana Vollala,
Department of Anatomy,
Melaka Manipal Medical College (Manipal Campus),
International Centre for Health Sciences,
Manipal-576104,
Karnataka State - INDIA
Phone: 91-820-2922642
Fax: 91-820-2571905
Email: [email protected]
Bouillanne, P. J.; Batt, M.; Hassen-Khodja, R.; Declemy, S.
& Pittaluga P. Anatomic bases for compression of the
superior gluteal artery at the level of the gluteal canal.
Surg. Radiol. Anat., 21:309-12, 1999.
Cook, A. M. & Dyet, J. F. Case report: Percutaneous
angioplasty of the superior gluteal artery in the treatment
of buttock claudication. Clin. Radiol., 41:63-5, 1990.
Hassen-Khodja, R.; Batt, M.; Michetti, C. & Le Bas, P.
Radiologic anatomy of the anastomotic systems of the
internal iliac artery. Surg. Radiol. Anat., 9:135-40, 1987.
Jutiano, P. J.; Bosse, M. J. & Edwards, K. J. The superior
gluteal artery in complex acetabular procedures. A
cadaveric angiographic study. J. Bone Joint Surg.,
76A:244-8, 1994.
Kida MY, Takami Y and Ezoe K. The ramification of the
superficial branch of the superior gluteal artery.
Anatomical basis of a new gluteus maximus
myocutaneous flap. Surg Radiol Anat., 14:319-23, 1992.
Standring, S. Gray’s Anatomy. 39th edn. Elsevier Churchil
Livingstone, 2005. pp.1361, 1362, 1547, 1548.
98
Received: 06-10-2006
Accepted: 22-12-2006